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At least 1,063 records · Page 59Linked to original sources
PubMed2000

Intracranial pressure monitoring in severe traumatic brain injury--results of a Canadian survey.

OBJECTIVE: The purpose of this study was to obtain information from Canadian neurosurgeons regarding their opinions on, and utilization of, intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI). METHODS: A brief survey was sent to practicing Canadian neurosurgeons questioning them about their utilization of, and confidence in, intracranial pressure monitoring in the management of patients with severe TBI. RESULTS: One hundred and ninety-six surveys were mailed. There were 103 responses for a response rate of 52.6%. The vast majority of responding neurosurgeons (98.1%) utilized ICP monitoring in the management of patients with severe TBI, with most (63.4%) using it in more than 75% of their patients, 14.9% using it in 50-75% of patients, 14.9% in 25-50% of patients, and 6.9% using it in less than 25% of patients. The level of confidence that routine monitoring improves outcome from severe TBI ranged from 23.3% having a low level of confidence, 56.3% having an intermediate level of confidence, to 20.4% having a high level of confidence. Most respondents (78.6%) felt that some form of prospective trial evaluating the role of ICP monitoring in improving outcome from severe TBI was warranted; 17.4% felt such a trial was not warranted and 3.9% were uncertain. CONCLUSIONS: While ICP monitoring has gained almost universal acceptance among responding Canadian neurosurgeons, their level of confidence that routine monitoring improves outcome from severe TBI was quite variable, with only 20.4% of respondents having a high level of confidence. Over 75% of respondents felt that some form of prospective trial evaluating the utility of ICP monitoring is warranted. This information is being used in consideration of a prospective trial addressing this issue.

Attitude of Health Personnel↗
PubMed1999

Noninvasive respiratory monitoring.

Advances in technology now permit a variety of noninvasive respiratory monitoring options for clinicians. Perhaps a more complex issue is determining how much monitoring is needed as part of routine patient care. Often, practitioners take a "more is better" approach. This reasoning is justified in critical care, because, in theory, the more information clinicians have available to them, the more likely they are to make accurate assessments and proper therapeutic interventions. If one fails to properly understand the physiologic significance and clinical limitations of the numbers or waveforms from the monitor, however, patient care may not improve and, even worse, may be compromised. Therefore, proper training in all aspects of respiratory monitoring should be a basic and fundamental component of any critical care nurse training program. There are important cost considerations to be taken into account with continuous respiratory monitoring. The financial impact as it relates to care of the critically ill patient is often difficult to assess. Issues of cost-effectiveness are often justified because of the complex nature of caring for these patients and their need for intensive clinical observation and evaluation. The fact that many aspects of cardiopulmonary assessment can now be determined noninvasively is an important advantage over more invasive technologies and their associated risks. Clearly, monitoring techniques such as pulse oximetry and capnography do not eliminate the need for arterial blood gases and other invasive cardiopulmonary monitoring techniques. Rather, when appropriately applied, noninvasive monitoring has the potential to reduce the frequency of certain invasive procedures and still provide valuable information to nurses and other health care practitioners.

Airway Resistance↗
PubMed1998

Home health monitoring.

Due to the general aging of society, increasing national medical expenditures are becoming a serious problem. It is thus highly desirable to reduce the need for medical services by maintaining the population in good health. Intensive monitoring of health parameters will become a necessary means for attaining good health at all times. Technology for health monitoring, however, is only recently being developed. A concept of home health monitoring is proposed by which health parameters are automatically monitored at home without disturbing daily activities. There are many attempts being made to realize this concept. This article reviews these attempts at developing home health monitoring techniques, which include monitoring during sleep, via the bath tub or toilet seat, as well as during daily activities. Preliminary studies show that home health monitoring can be achieved even by means of simple sensors and instruments. There are also many possible applications for advanced technologies. Potential future technologies for home health monitoring include automatic blood pressure measurement via the toilet seat, automatic blood sampling with a device mimicking a mosquito, and artificial noses for detecting smells.

Activities of Daily Living↗
PubMed2000

[Clinical experience of long-distance electronic fetal heart rate monitoring system by telephone].

OBJECTIVE: To explore the value of the long-distance electronic fetal heart rate monitoring system by telephone and explore a new way of self-monitoring at home for pregnant woman. METHOD: 204 high risk pregnant women came to our clinic were enrolled in this study. Complications included pregnancy induced hypertension (PIH), intrauterine growth retardation (IUGR), anemia, diabetes, hemolysis, nephropathy. In the study group, 97 women took the terminal part of the fetal heart rate monitoring system home and were requested to auscultate and count fetal heart rate three times a day, while another 107 cases did the self monitoring by fetal movement counting daily and served as control group. For the study group, whenever woman felt any abnormality of her baby, she could contact the long-distance electronic fetal heart rate (FHR) monitoring center in hospital by telephone immediately. The signal of fetal heart beat and fetal movement was converted and analyzed in the electronic FHR monitoring center by computer at the same time. The fetal heart rate curve was printed out, and diagnosis and management could be made. Age, gestational weeks, high risk factors, abnormal non-stress test (NST), Apgar score and birth weight of newborn were analyzed between the experimental and control group retrospectively. RESULTS: There were no obviously differences in age, gestational weeks, weight of newborn, high risk factors between the 2 groups. The incidence of abnormal NST and Apgar score of newborn were significantly higher in the study group than that in the control group, while the incidence of neonatal asphyxia was significantly lower. CONCLUSIONS: This study suggested that the long-distance electronic FHR monitoring by telephone was a reliable, sensitive and applicable method of self-monitoring for pregnant woman at home, use of this system could decrease the incidence of fetal distress, brain damage and perinatal mortality, thus improves the quality of perinatal care.

Adult↗
PubMedDate not supplied

Southern California's marine monitoring system ten years after the National Research Council evaluation.

In 1990, the National Research Council (NRC) published two in-depth assessments of marine environmental monitoring effectiveness. The first of these, Managing Troubled Waters: The Role of Marine Environmental Monitoring, provided a national perspective and the second, Monitoring Southern California's Coastal Waters, examined the specifics of monitoring design and implementation in a densely populated, highly urbanized coastal region. The reports include explicit recommendations about the need for greater regionalization of monitoring efforts, supported by greater standardization of field, laboratory, and data analysis methods. They also identified the need for centralized data management and for greater flexibility in the language of standard discharge permits, flexibility that would permit discharge agencies to more readily participate in regional monitoring and research programs. Other recommendations identified a need for EPA and NOAA to focus on creating a national monitoring program structured as a network of coordinated local and regional efforts. Finally, the NRC emphasized the need for better reporting and for periodic review of monitoring's relevance to management concerns. In this paper, we use southern California as a test case to assess progress made in implementing the NRC's recommendations. We review progress made on each recommendation and discuss the features of the regulatory and management climate that contributed to or impeded this progress. We also consider whether, and to what extent, the NRC's recommendations remain relevant in the present context.

California↗
PubMed1992

Invasive hemodynamic monitoring during cardiopulmonary resuscitation in a community hospital emergency department.

Monitoring the effects of resuscitation efforts in a community emergency department are limited primarily to noninvasive techniques. Coronary perfusion pressure (CCP) has been used as a predictor for successful resuscitation. The authors investigated the feasibility of measuring the CPP in a community emergency department and incorporating the CPP into decisions for managing the resuscitation effort. During a 7-month period, the authors prospectively studied 77 nontraumatic, normothermic adults in cardiopulmonary arrest who were treated in the emergency department. Fifty-one patients underwent invasive monitoring and 26 patients entered a control (noninvasive monitoring) group. Successful CPP monitoring was accomplished in 84% of the patients; the average time to obtain an initial CPP was 12.1 +/- 7.3 minutes. Twenty patients had a return of spontaneous circulation, but no patient survived to hospital discharge. There was no significant difference in return of spontaneous circulation between patients in the invasively monitored and the noninvasively monitored group. Coronary perfusion pressure monitoring had a positive influence on the management of three patients. This study showed that CPP monitoring is feasible in a community hospital, but further studies are needed to better define the effects of CPP in resuscitation effort outcome.

Aged↗
PubMed2005

Therapeutic drug monitoring and the inhibitory quotient of antiretroviral drugs: can they be applied to the current situation?

Therapeutic drug monitoring is attracting growing interest as a means of increasing the effectiveness of antiretroviral therapy and of decreasing its toxicity, although data supporting this strategy are still scarce. Currently, nucleoside analog reverse-transcriptase inhibitors (NARTI) are not candidates because their effect depends on their active intracellular form and not on plasma concentration. Protease inhibitors (PI) and non-nucleoside analogue reverse-transcriptase inhibitors (NNARTI) meet the criteria for therapeutic drug monitoring. The main limitations are that the parameters to be monitored in order to measure exposure to the drug and the effective concentration of the drug have not been well defined. The few studies performed in treatment-naive patients have demonstrated that monitoring improves therapeutic efficacy. This strategy will be particularly useful when the risk of subtherapeutic or toxic concentrations is especially high (pharmacokinetic interactions, intestinal malabsorption, adverse effects, virological failure without obvious cause, pregnancy, children). Although it remains to be standardized, the inhibitory quotient integrates pharmacological and virological parameters and is useful in patients with prior virological failure. Any therapeutic drug monitoring program should be accompanied by measures to monitor and improve treatment adherence. There are good reasons to believe that therapeutic drug monitoring can be useful to improve treatment in specific circumstances. However, before its widespread use as a routine method can be recommended, the parameters to be used should be standardized and studies with appropriate methodology should be performed to define the role of therapeutic drug monitoring in distinct clinical situations.

Algorithms↗
PubMed1991

A comparison of facial nerve monitoring systems in cerebellopontine angle surgery.

The use of peripheral nerve monitoring during skull base surgery is becoming a more common procedure. One widely used method (Jako) detects surface muscle contraction, which can be transduced into an audible signal. A 200 microsecond square wave current can be delivered periodically, in order to identify the nerve and verify its integrity. Another monitoring method has been developed, which provides a continuous audible needle electromyographic (EMG) feedback signal from computer averaging of a monopolar low impedance constant voltage stimulus. This study compares facial nerve preservation and postoperative facial nerve function results of three groups of cerebellopontine angle surgical cases: 38 cases performed with no monitoring; 29 cases done with Jako motion detection monitoring; and 41 performed with evoked needle EMG audible feedback monitoring. Postoperative facial nerve function is evaluated using the House-Brackmann grading system. Each of the three study groups are matched for a time at which postoperative evaluation was made. Analysis of results reveals that in addition to the expected increase in facial nerve preservation rates when monitoring is in use, the near real-time feedback provided by audible evoked EMG results in a significant reduction in permanent postoperative facial nerve dysfunction. Using evoked monitoring, a greater proportion of the cases had a final outcome of class I or II results, compared to those cases performed using Jako motion detection monitoring.

Cerebellar Neoplasms↗
PubMed1990

Home monitoring in infants and children with obstructive apnea.

It becomes apparent that the decision to prescribe home monitoring for the child who has, or is thought to be at risk for, obstructive apnea is not a straightforward one. There have been no studies documenting the effectiveness of home monitoring in this population. The risk of obstructive apnea in some children clearly supports the use of an obstructive apnea detection system. Unfortunately, the current home monitors are not designed to detect obstructive apnea. These monitors may alert parents to obstructive apnea by identifying the changes in heart rate that can accompany these episodes, but this warning may not be timely. There are a number of potential costs that may accrue to families who monitor their children. In some instances the "costs" of home monitoring may lead to failure of parents to comply with the treatment or to neglect of other aspects of their child's treatment regimen, thereby effectively increasing the child's risk of obstructive apnea. To achieve the maximum benefits of home monitoring requires high levels of commitment on the part of both the child's physician and his family. Parents need thorough preparation and continuous logistic and professional support if they are to carry out this monitoring. The physician should not need to provide all of this support, but he or she should expect to function in a co-ordinating capacity on behalf of the child and family.

Child↗
PubMed1989

Home monitoring in Hawaii: the first 1,000 patients.

By February 1988, 1,000 Hawaii infants had been prescribed cardiorespiratory monitors for use at home. By 1986, 12.3/1000 live births were being monitored, principally for apnea related to prematurity but also following Apparent Life Threatening Episodes, (ALTE) as subsequent siblings of Sudden Infant Death Syndrome (SIDS) victims, and for an increasing variety of other conditions. Less than 3% of families used the monitor less than 1 week; 30% discontinued sooner than the program recommended. Twenty-seven percent of the monitored infants were judged to have experienced real apnea or bradycardia while on their monitors. Seventeen of the patients are known to be dead, with 2 of these deaths occurring while the symptomatic patient was not monitored. Parents responding to a quality assurance questionnaire were highly enthusiastic about monitoring and felt it was a source of reassurance rather than a stressor. Major problems encountered by monitoring families were related to equipment performance.

Female↗
PubMed1988

[Instrumental monitoring in anesthesia. Results of a rapid electronic data processing survey at the time of the 1987 Central European Congress in Munich].

During the ZAK 1987 in Munich we performed a poll concerning monitoring during anaesthesia. 200 questionnaires could be evaluated. A majority of 2/3 rd monitored regularly blood pressure, ECG, FiO2, minute ventilation and ventilation pressure. These quantities were monitored independent of a presumably increasing anaesthesia risk associated with three clinical cases. Only blood pressure and ECG were considered as mandatory by a majority of 2/3 rd. Monitoring variables related more to the anaesthesia machine lide FiO2, minute ventilation, and ventilation pressure did not reach a 2/3 re majority. 78% detected at least once in their business life time a life threatening complication by monitoring devices earlier than by so called clinical signs. EEG and capnometer were the most frequent quoted monitors. Monitoring of neuromuscular blockade and intraoperative awareness was considered as a relevant problem only by 22%. 20% agreed to additional monitoring on the general ward while 2/3 rd disagreed.

Adult↗
PubMed1984

A prospective study of the impact of home monitoring on the family.

Fourteen families whose infants required home monitoring for apnea were followed for approximately 5 years from the initial contact (1977). Each family received at least three psychiatric interviews and two follow-up contacts. Effects on the monitored infant, siblings, and parents were examined in open and semi-structured interviews. At first follow-up (mean of 21 months after monitoring discontinuance), seven of 14 monitored children were characterized as spoiled by parents. By the second follow-up, 2 1/2 years later, nine children showed speech, learning, and motor problems; five of these nine children had required resuscitation during their initial episode. Apnea severity was also related to both duration of monitoring and number of additional psychiatric interviews requested by parents or staff. Of 16 older siblings, 12 had psychological problems reported by their parents at first follow-up; these problems appeared to be largely resolved by the second follow-up, although three children were still having problems that caused parental concern. Monitoring, as well as the apnea itself, caused substantial distress manifested in depression, fatigue, and anxiety in many parents, particularly mothers. However, despite their considerable distress, none of the families discontinued monitoring prematurely. Results of the study indicated that the monitoring experience can be divided into four phases: doubt/acceptance, dependence/frustration, discontinuance, and late effects, with substantial differences in parents' responses occurring only in the last two phases.

Female↗
PubMed1980

Effect of fetal monitoring on cesarean section rates.

Electronic fetal monitoring (EFM) and cesarean sections (CS) have been studied in 14,484 patients delivered between 1970 and 1975. The primary CS rate for those monitored was 107/1000, and for the unmonitored was 57/1000. Multivariate analysis of these data shows that most of the increase in CS rate associated with monitoring is attributable to inherent differences between monitored and unmonitored patients. Furthermore, the association between monitoring and CSs was not homogeneous among sub-groups. Cesarean sections were relatively less frequent in monitored nulliparas with malpresentation and more frequent in otherwise normal monitored multiparas. These opposing effects tended to balance each other. During the study period the primary CS rate rose from 4.3 to 11.2%. This increase was strong in unmonitored patients and was primarily due to operations undertaken for fetopelvic disproportion. We cannot therefore attribute much of the increasing CS rate at our hospital to fetal monitoring.

Cesarean Section↗
PubMedDate not supplied

Retrospective analysis of risks associated with an umbilical artery catheter system for continuous monitoring of arterial oxygen tension.

We reviewed retrospectively the incidence of complications encountered with two different umbilical artery catheters (UACs): a silicone-rubber end-hole catheter and an electrode-tipped, side-hole catheter for continuous, invasive monitoring of arterial oxygen tension (PaO2). During calendar year 1989, there were 457 admissions to the neonatal intensive care unit: 168 patients had placement of a UAC. Two of these were admitted only briefly for cardiac catheterization and were eliminated from analysis. One patient had both types of catheters placed sequentially. Thus the data on 166 patients with 51 PaO2 monitors and 116 silicone-rubber UACs were evaluated. The patients who had a PaO2 monitor UAC had a lower mean birth weight than those in the other group (1621 +/- 1043 gm vs 1972 +/- 1048 gm; p = 0.0473). The catheter life span was not different between the groups, with a range of 1 to 16 days for PaO2 monitors and 1 to 27 days for silicone-rubber UACs. Inability to withdraw blood, poor blood pressure tracing, or both conditions resulted in catheter removal for 5 of 51 PaO2 monitor UACs and 4 of 116 end-hole UACs. The incidence of these problems did not differ significantly between the two groups. There were no cases of thromboembolic complications in the patients who had a PaO2 monitor UAC, whereas two of the silicone-rubber UACs were removed because of perfusion problems in the lower limbs, which resolved with decannulation. We conclude that the use of the PaO2 monitor UAC allows for continuous, invasive monitoring of PaO2 without any significant increase in risk compared with that for the silicone-rubber end-hole UAC.

Catheterization, Peripheral↗
PubMed1995

Cost-effectiveness of induction of labour versus serial antenatal monitoring in the Canadian Multicentre Postterm Pregnancy Trial.

OBJECTIVE: To determine the cost-effectiveness of induction of labour versus serial fetal monitoring while awaiting spontaneous labour in postterm pregnancies. DESIGN: Cost-effectiveness and cost-minimization analyses conducted as part of a Canadian multicentre randomized clinical trial. SETTING: Twenty-two Canadian hospitals, of which 19 were teaching hospitals and 3 were community hospitals. PATIENTS: Women with uncomplicated pregnancies of 41 or more weeks' gestation were randomly assigned to induction of labour or serial antenatal monitoring. Of the 3418 women enrolled, no data were received on 11. Therefore, results were based on data from 1701 women in the induction arm of the study and 1706 women in the monitoring arm. MAIN OUTCOME MEASURES: Perinatal mortality and neonatal morbidity, rates of cesarean section and health care costs. Hospital costing models were developed specifically for the study. Data on use of major resources (e.g., length of hospital stay, surgical procedures, major diagnostic tests and procedures, and medications) for all trial participants were collected and combined with data on minor tests and procedures (e.g., laboratory tests) abstracted from a detailed review of medical records of a sample of patients. RESULTS: Because the results of the clinical trial showed a nonsignificant difference in perinatal mortality and neonatal morbidity between the induction and monitoring arms, the authors conducted a cost-minimization rather than a cost-effectiveness analysis. The mean cost per patient with a postterm pregnancy managed through monitoring was $3132 (95% confidence interval [CI] $3090 to $3174) and per patient who underwent induction of labour was $2939 (95% CI $2898 to $2981), for a difference of $193. The significantly higher (p < 0.0001) mean cost per patient in the monitoring arm was due mainly to the costs of additional monitoring and the significantly higher rates of cesarean section among these patients. Estimated conservatively, the savings resulting from a universal policy of managing postterm pregnancies by induction of labour in Canada may be as high as $8 million a year. CONCLUSIONS: A policy of managing postterm pregnancy through induction of labour not only results in more favourable outcomes than a monitoring strategy but does so at a lower cost.

Cost Control↗
PubMed1995

A new method of infant monitoring: for use at home and hospital.

AIM: To test a New Zealand originated, designed and funded remote infant heart rate monitor in the home and hospital settings (temporarily named the King Monitor) for accuracy and reliability. METHODS: The units were pretested using ECG simulators and on infants already being monitored in the neonatal unit. Longer term trials on hospital infants and infants being simultaneously monitored at home were then conducted. RESULTS: Interference and electrode problems were corrected during the pretesting phase. The unit worked accurately when compared with the standard neonatal heart and respiratory rate monitor in hospital and appeared in some infants to give earlier warning of problems than the standard home apnoea monitor. CONCLUSION: This simple to use monitor worked reliably and accurately under a wide variety of settings and with varying sized infants. In addition, the lack of direct connection between the infant and the control unit allowed freedom of movement of normal infants around the cot or bassinet. The monitor will require to be adapted for portable use at home and during travel.

Electrocardiography↗
PubMed1993

Electronic fetal monitoring: a Canadian survey.

OBJECTIVES: To determine the current status of electronic fetal monitoring (EFM) in Canadian teaching and nonteaching hospitals, to review the medical and nursing standards of practice for EFM and to determine the availability of EFM educational programs. DESIGN: National survey in 1989. PARTICIPANTS: The directors of nursing at the 737 hospitals providing obstetric care were sent a questionnaire and asked to have it completed by the most appropriate staff member. The response rate was 80.5% (593/737); 44 hospitals did not have deliveries in 1988 and were excluded. The remaining hospitals varied in size from 8 to 1800 (mean 162.1) beds and had 1 to 7500 (mean 617.1) births in 1988; 18.8% were teaching hospitals. RESULTS: Of the 549 hospitals 419 (76.3%) reported having at least 1 monitor (range 1 to 30; mean 2.6); the mean number of monitors per hospital was higher in the teaching hospitals than in the nonteaching hospitals (6.2 v. 1.7). Manitoba had the lowest mean number of monitors per hospital (1.1) and Ontario the highest (3.7). In 71.8% of the hospitals with monitors almost all of the obstetric patients were monitored at some point during labour. However, 21.6% of the hospitals with monitors had no policy on EFM practice. The availability of EFM educational programs for physicians and nurses varied according to hospital size, type and region. CONCLUSIONS: Most Canadian hospitals providing obstetric services have electronic fetal monitors and use them frequently. Although substantial research has questioned the benefits of EFM, further definitive research is required. In the meantime, a national committee should be established to develop multidisciplinary guidelines for intrapartum fetal assessment.

Canada↗
PubMed1995

Random zero sphygmomanometer versus automatic oscillometric blood pressure monitor; is either the instrument of choice?

The Hawksley random zero sphygmomanometer was designed to eliminate observer bias and two digit preference. We have measured blood pressure (BP) in a group of 62 young adults (median age 26.1 years, range 20.2-31.3 years) with reflux nephropathy under standardised conditions (that is, in the morning, after a 2 h supine rest, before venepuncture, using a standard 12 x 23 cm adult size cuff appropriate for the machine used) utilising the random zero sphygmomanometer and the automatic oscillometric BP monitor (Dinamap 8100, Critikon). Seven consecutive recordings of right brachial BP at intervals of 2 min were taken using each instrument alternatively, and the first reading was discarded. The first instrument used to measure BP was alternated between patients to eliminate bias on instrument preference. Random zero sphygmomanometer was used as recommended by the manufacturers and Korotkoff phase V was used to measure the DBP. The observer and the equipment used were the same throughout the study period. The mean SBP and DBP were calculated to the nearest 1 mm Hg utilising the three recordings taken by each instrument. The limits of agreement and the repeatability coefficients for each method of measurement were assessed utilising the statistical method described by Bland and Altman in 1986. The correlation coefficients among random zero and automatic oscillometric BP monitor for SBP and DBP measurements were 0.84 and 0.67, respectively. The average BP (mean of random zero and automatic oscillometric BP monitor measurement) plotted against the difference between the two methods of measurement showed no relation between the difference and the average of measurement in the ranges of BP studied, that is, between 100 and 160 mm Hg systolic and 55 and 100 mm Hg diastolic. The mean of difference between random zero and automatic oscillometric BP monitor for SBP was -6.45 (s.d. 6.07) and for DBP +10.77 (s.d. 8.16) mm Hg. The limit of agreement for SBP measurement was +5.69 to -18.59 mm Hg and for DBP was +27.09 to -5.55. The repeatability coefficients of random zero and automatic oscillometric BP monitor for systolic and diastolic measurements were 8.64 and 7.04, and 9.72 and 6.62, respectively. Bland and Altman analysis indicates major differences between the two methods of measurement. The automatic oscillometric BP monitor could on average over-read the systolic by 6.45 mm Hg and under-read the diastolic by 10.77 mm Hg compared with that of random zero. Furthermore, the limits of agreement were wide enough for a normotensive to be inadvertently defined as a hypertensive on machine error alone. This clearly indicates that automatic oscillometric BP monitor and random zero BP measurements cannot be used interchangeably in clinical practice. Furthermore, the repeatability coefficients, which should ideally be zero, are too large for either instrument to be considered as the gold standard for BP measurement, although that of automatic oscillometric BP monitor was superior to that of random zero. This study highlights the importance of using nomograms generated by the same method of measurement for comparison both in paediatric and adult practice for correct interpretation of BP.

Adult↗